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f <br />1 S' y,. <br />4 M WELL/PUMP PERMIT - <br />SAN JOAQUIN COUNTY ENvIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 - (209) 468-342.0 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOS ADORESs 1739 N. DURHAM FERRY RD.. CrcY/ZIP TRA_ t V 9 5111 A <br />'CROSS STREET CA 33 Q > <br />AAN Z 5 5 - 31 - 0 2 3 PARCEL SIZE 1 • 1 LANG USE APPL(CATrON �f <br />- I'll <br />OWNER NAME PHONE 415-533-0322 N <br />OWNER ADDRES 'C'] �22i1CrScc> <br />CITY/STATE/ZIP TRAY - 9xy-3-a <br />CONTRACTOR Delta Fume GTnf't{T()N ARMAT 7R MOTOR WORKS t rh36t7:. 209_4 <br />._ G-961�. <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP Stockton. CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 N C-61 0 D-09 0 Other <br />NUMBER <br />CITY/STATE/ZIP <br />PHONE <br />EXPIRATION DATE 0 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y ' <br />INTENDED USE omcstic/Private 0 Irrigation/Agricultural 0 industrial 0 Water Quality Monitor ng Township CSoil SamplRange glCharacteriz Section <br />- <br />0 Public Water System <br />If difrerenl from Owner a or y am amo <br />on ac ame or lone um or <br />TYr'F__:____OF WQRK u X& Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monftoring tNelf(s) # of wells D Soil Boring(S) 4 of borings # or borings <br />0 Out -Of -Service Wel( Fj Geotecnnicaf <br />Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Jew Pump ❑ PUmD Re lacement Pump Repair <br />WELL CONSTRUCS WN 0 Raise Well Casm <br />Drilling Method 0 Mud Rotary C Air Rotary Z, Auger 0 Cable Tool u Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br />C Conductor Casing in diameter / Conductor Casing Depth ft in diameter <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />❑ Steel 0 Plastic ❑Stainless Steel ❑ Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb bog/5-10 ga/ water) ❑ Sand Cement <br />u Bentonite (20% solids) D Oilier sock mix/7 gal water <br />Grout Placement Method 0 Pumped 0 Free Fall ❑ Other <br />❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br />I_`.- D Concrete Pedestal Dimensions: Width It Length ft Thick <br />in ❑Christy Box ❑Stove Pipe <br />PUMP " Submersible❑ Turbine ❑ Other / '1 <br />_ HP _ Pump Set /S� U Standing Water Level �Q ft <br />1 HEREBY CER THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT .1 AM IN COMPLIANCE' WITH ALL <br />WORKERS COMPI'N <br />MINIMU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED <br />TITLE CEO DATE 717/2017 <br />EP RTMENT USE ONLY <br />Application Accepted By s/ <br />Date ��/1-7 <br />Grout Inspection By <br />Date <br />Pump Inspection By 2n:? <br />Date <br />Soil Boring Inspection By <br />COMMENTS Date <br />lv <br />EHD 43.06 <br />8/04/08 <br />Area-6/Z� Employee <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Date Permit/ <br />Service R` quest # <br />Invoice # <br />Well ID# <br />WELL /PUMP PERMIT <br />